Characteristics of studies from which subthemes were derivedType of PIMs; age focus*; setting (number of references)

Illustrative quotations“Italicised text”=primary quote (ie, quote from a study participant from an included paper)‘Non-italicised text’=secondary quote (ie, quote from study authors’ findings from an included paper)

“When I saw the list of patients [to be discussed with the researcher], I was quite happy about the prescriptions…but obviously when you look at them in more detail there are anomalies there that ought to be either checked on, reviewed or even altered”46

“He gets very worried and excitable if you attempt to change anything… even just something minor would cause him virtually a breakdown”46“We can't predict the effect [of deprescribing] for the individual patient”31“It's scary to stop a medication that's been going for a long time, because you kind of think am I opening a can of worms here, because I don't know what the reasons were for them starting that medication. To explore all that will take, you know, I can't do all that now, I will have to do that another time”40“I suggest to them that ideally we should try to get them off of that, but if they're saying, been there, done that, that didn't work for me when I came off of this, I don't think it's worth getting into a big knock-down drag-out [fight] with them or having them leave my practice over this issue”38

‘In their [the physicians’] view psychotropic medication helps the elderly patient remain functional and is the least problematic solution… The physicians stated that they often do not see side effects and that patients often do not report them…’35

“There is a paradox concerning older patients. You do not want to make them grow dull, but on the other hand you know their chronic problems, and you know that at their age the drugs are not so addictive. You want them to keep their minds clear, but on the other hand I do have a tendency to be permissive to older patients”34“…It treats our own pain as well as our patients’ pain, 'cos we want to help people and make people feel better. So if we give people something and make them feel better, then everybody seems to be happier”39

“Let's pretend it’s an octogenarian…if it's gonna make the patient feel better, I don't care if the patient's on it for the rest of their life”38‘Most frequent concern identified was the difficulty anticipated in persuading older patients to withdraw after years of using benzodiazepines’36“In my experience, patients get hooked on PPIs, it is almost addictive like heroin and people appear to experience severe indigestion symptoms on attempting to stop them”44

‘They [the physicians] recognized that the inappropriate use of psychotropic medication for elderly patients was a public health problem, but they felt that it was beyond the scope of the individual physician’35“(…) I ask them if it should be a sleeping pill or another of the available options and mostly they have a need for sleeping pills”43“I have been running this practice for twelve years. I took it over from an older colleague. I took over all his patients. They were mostly old people. Prescribing policy has been rather liberal, and I have continued this policy”34

“I don't have enough time for education about the newest information on psychiatric disorders, and better communication with specialists would be very helpful”41‘Side effects are not always recognised as such’ 32“When house officers come on our ward, they haven't necessarily been trained in geriatrics. So they arrive here, and then they start with 10 mg of morphine every four hours. That's too much” (Hospital based geriatrician)49“You look at the medication list and want to reduce it but then you can't find things you can eliminate”31

Information/influencers

Lack of evidence303133

Polypharm (3);Older age (3);Primary care (3)

“To me, the guidelines are kind of a hindrance. At the moment they do not cater for older patients”31

“The problem is that the medication lists of the doctors involved are not exchanged and are consequently inconsistent”31“One has discovered that they might have completely different expectations than what the doctor had from the beginning. Do they want to survive for five more years or? And so on. What are their expectations?”30‘Medicines, (mainly for chronic conditions) were sometimes not appropriately reviewed because there was no written information on indication and follow-up or because this was not readily available’49“Sometimes the older people decide for themselves to reduce some of their medication or to adjust the doses without telling their GP. Therefore as their GP you can have the wrong impression about their medication intake…”32

‘When existing guidelines are debated, GPs felt deceived and insecure… The importance of individualising treatment was also expressed and many guidelines were perceived as too rigid leading to a standardized ‘kit’ of medicines per indication…’30“I have difficulty not following the guidelines if I don't have good reasons to do so”31“When the hospital consultant recommends a treatment it's difficult… for us not to prescribe unless there is a very good reason. To some extent we feel obliged to carry on when they have initiated it”46

“(…) in such a situation it amounts to the sleeping pill, because everybody else's need is the sleeping pill, and I would have to fight tooth and nail if really I wanted to avoid this”43

“They (RACF nurses) called me on the carpet to tell me that withdrawing antidepressants was not a clever thing to do because the patient became angrier and resisted care. They therefore demanded that I reinstate medication”42

“…these types of people and they tend not to want to help themselves, you know they won't take the hypnotherapy and they won't go to yoga classes and they won't do anything else. They just want a quick fix”37

“I think they have horrible lives, a lot of them… I think it's a combination of all things, their health, their social circumstances… I think a lot of people are on antidepressants because of everything put together. And you can't… change most of the factors that cause it”40

Discrepant goals to prescriber 3033

Polypharm (2);Older age (2);Primary care (2)

“I kind of get aggravated that half of the medicines that I think are totally rubbish are the ones that the patient really wants to take”33

“(…) then he gets something and he continues this pill, and then the issue is over for him, then it's quiet, and then he has his pill and then he sleeps through, and from time to time you may enquire, it if occurs to you while looking at his medication”43“When we work in a large health centre, then we sign prescriptions for each other…when a colleague is absent, we issue prescriptions for him that day. Any prescription I issue is my responsibility, but if you are asked to prescribe a particular drug [for a colleague] then you sign it in the reception. I don't check which other drugs that person uses”47

‘The GPs rarely contact colleagues, for example, hospital specialists, as there is a perceived lack of routines for this as well as an informal understanding not to pursue colleagues’ motivations for prescriptions’30

“The number of medications grows slowly. There is a complaint, we give new medication, it continues without really stopping it after a while… and it is our responsibility to try and withdraw it from the patient”32

“They feel that unless they are on a tablet for it then they are not having any treatment. There are a lot of those kinds of people”40

Regulatory

Quality measure driven care33

Polypharm (1);Older (1);Primary care (1)

“Another factor that we experience at the VA is these electronic reminders that tell you to do things…What I do really depends on who is in front of me…So the reminder comes up and it makes no sense. This guy's LDL is 101.8… Should I go from 40 to 80 of simvastatin? And what's the risk and benefit there?”33

*Age focus refers to the indicative age group of patients who were the focus of participant discussions, as suggested by the terms used in each article, which did not specify the exact age ranges.